Some gastrointestinal symptoms can be managed with lifestyle and dietary measures or OTC medicines but, as Steve Titmarsh explains, persistent symptoms need further investigation…

Gastro-oesophageal reflux disease (acid reflux or GORD) is caused by stomach contents moving up into the oesophagus and/or the mouth. It happens when the ring of muscle at the top of the stomach where it connects to the oesophagus (the lower oesophageal sphincter) relaxes at the wrong time and allows liquids in the stomach back into the oesophagus.¹

Drugs that can affect oesophageal motility, such as nitrates, anticholinergics and tricyclic antidepressants, or which damage the mucosa (eg, NSAIDs, potassium salts, alendronate) may be also associated with GORD.²

Many people have reflux from time to time, normally after a meal. But some people have regular symptoms of heartburn and regurgitation.¹

Mild symptoms can be managed by losing weight, stopping smoking, avoiding foods that trigger reflux, avoiding eating too late and wearing loose clothing. People who have symptoms at night may find raising the head of their bed 15–20cm helps.¹

Antacids that neutralise stomach acid, or alginates that float on top of stomach contents to keep acid away from the oesophagus, can help manage symptoms as can histamine receptor antagonists that reduce stomach acid secretion.

Proton pump inhibitors (PPIs) for four to eight weeks may be needed for moderate to severe symptoms or for people who do not respond to lifestyle measures or treatment for mild symptoms.³

Hiatus hernia

GORD can be a result of hiatus hernia, a condition caused by part of the stomach moving up into the chest through an opening – hiatus – in the diaphragm.⁴

Other than reflux, hiatus hernia does not usually produce symptoms and its cause is not completely understood. People over 50 years old who are overweight or pregnant women are more likely to be affected – more than 1 in 3 people over 50 years old are thought to have hiatus hernia.⁴

People with hiatus hernia may find their symptoms are reduced by eating smaller meals more frequently and not lying down within three hours of eating or drinking. Avoiding food or drink such as alcohol, caffeine, chocolate, tomatoes, fatty foods, spicy foods and acidic food or drinks that make symptoms worse may help.

Blocks under the bed to raise the head by about 20cm can also help. Using extra pillows should be avoided because it puts extra pressure on the abdomen. Surgical repair of a para-oesophageal hiatus hernia, where the stomach pushes up through an opening in the diaphragm next to the oesophagus, is necessary only when it might cause serious complications. For hernias that move in and out of the chest area – so called sliding hernias – surgery is recommended only when lifestyle measures do not work.⁴

Taking an antacid, alginate, H2-receptor antagonist or PPI may help relieve symptoms.

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a chronic condition affecting the digestive system, described as a disorder of gut-brain interaction. Although not fully understood, it is thought to involve biological, psychological and social factors.⁵

Common symptoms include stomach cramps, bloating, diarrhoea and/or constipation, flatulence, and sometimes an urgent need to move the bowels. People may also complain of lethargy, feeling nauseous and heartburn. Symptoms vary from person to person and can change with time. It is not a serious threat to physical health and is not associated with an increased risk of cancer or other bowel-related diseases.⁵

Possible causes include:

• changes in gut microbiome
• a change in the brain-gut interaction involving abnormal processing of nerve signals from the gut
• infection
• foods such as alcohol, caffeine, spicy and fatty foods
• drugs such as antibiotics
• psychological factors, including stress, anxiety and/or depression.⁵

Initially management should focus on adopting a healthy diet, regular exercise and mental wellbeing. Groups such as the IBS Network (www.theibsnetwork.org) provide information and support. Probiotic supplements may help but should be tried for at least 12 weeks.

If symptoms are mainly diarrhoea and/or bloating, it is advisable to reduce intake of insoluble fibre and reduce foods that exacerbate symptoms. If constipation is the main issue, soluble fibre supplements or foods high in soluble fibre may be beneficial. If there is no change after two months medical referral may be needed.⁵

Lactose intolerance

Inability to digest lactose because of a lack of lactase can lead to symptoms such as flatulence, diarrhoea, bloated stomach, stomach cramps and pains, stomach rumbling and feeling nauseous.⁶

Lactose is found in milk and dairy products. In the small intestine the enzyme lactase breaks down lactose into glucose and galactose that can then be absorbed by the body. Lactose intolerance in the UK is common among people of Asian or African-Caribbean descent. It tends to affect people aged 20 to 40 years, but people of any age may be affected.⁶

Lactase deficiency may be genetic: this is the most common cause when it is known as primary lactase deficiency. It can also be secondary to other causes such as gastroenteritis, coeliac disease, Crohn’s disease, ulcerative colitis, chemotherapy or long courses of antibiotics.⁶

Symptoms of lactose intolerance can be largely managed by a change in diet, by eating fewer foods containing lactose, replacing them with lactose-free alternatives or avoiding them altogether.

When changing diet it is important to consider what might be missing from the modified diet such as vitamins and minerals and other nutrients. So nutritional supplements might be necessary to replace nutrients that are not available from alternative food sources.⁶

Flatulence

Flatulence is a symptom common to digestive disorders discussed such as irritable bowel syndrome and lactose intolerance.

Swallowing more air than usual, for example, when smoking, chewing gum or swallowing large pieces of food that have not been chewed thoroughly, can result in excessive flatulence. Some food and drink can cause flatulence, especially those with a large proportion of unabsorbable carbohydrate such as beans, broccoli, cabbage, lentils, onions and apples.

And some drugs such as non-steroidal anti-inflammatory drugs, some laxatives, antifungals, statins and varenicline are associated with flatulence.⁷

Lifestyle measures such as a change in diet or exercise are usually enough to manage flatulence. Some people may find charcoal tablets or simethicone helpful. Dietary supplements such as alpha-galactosidase may be effective for some people, and probiotics can also help in cases of IBS in particular.⁷

While passing wind is normal, there may be signs that something more serious is causing flatulence. A visit to the GP may be necessary, for example, if someone is experiencing: persistent abdominal pain; recurring diarrhoea or constipation; unexplained weight loss; bowel incontinence; blood in faeces, or signs of infection such as high temperature, vomiting, chills, joint pain or muscle pain.⁷

^References

1. UpToDate. Patient education: Gastroesophageal reflux disease in adults (Beyond the Basics) (www.uptodate.com/contents/gastroesophageal-reflux-disease-in-adults-beyond-the-basics; accessed November 2022).
2. Patient.info. Gastro-oesophageal Reflux Disease (https://patient.info/doctor/gastro-oesophageal-reflux-disease; accessed November 2022).
3. British National Formulary. Gastro-oesophageal reflux disease (https://bnf.nice.org.uk/treatment-summaries/gastro-oesophageal-reflux-disease; accessed November 2022).
4. NHSinform. Hiatus hernia (www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/hiatus-hernia; accessed November 2022).
5. Clinical Knowledge Summaries. Irritable bowel syndrome. (https://cks.nice.org.uk/topics/irritable-bowel-syndrome; accessed November 2022).
6. NHSinform. Lactose intolerance (www.nhsinform.scot/illnesses-and-conditions/nutritional/lactose-intolerance; accessed November 2022).
7. NHSinform. Flatulence (www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/flatulence/#causes-of-flatulence; accessed November 2022).